LONG ISLAND BARIATRIC, PLLC

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1 PATIENT INFORMATION REFERRED BY: LAST NAME: FIRST NAME: MI: SOCIAL SECURITY # - - DATE OF BIRTH / / AGE MARITAL STATUS: Single Married Widowed Divorced Separated / SEX: MALE FEMALE ADDRESS APT # CITY STATE ZIP CODE HOME PHONE: ( ) CELL PHONE: ( ) EMPLOYER NAME: OCCUPATION BUSINESS PHONE: ( ) EMERGENCY CONTACT: RELATIONSHIP HOME PHONE: ( ) WORK/CELL: ( ) PREFERRED LANGUAGE: ETHNICITY: HISPANIC OR LATINO NON HISPANIC OR LATINO RACE: American Indian Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race White PREFERRED COMMUNICATION: Phone Portal Letter No Preference ADDRESS: HEALTH INSURANCE INFORMATION PLEASE SUBMIT ALL INSURANCE CARDS AND DRIVER S LICENSE / PHOTO ID FOR SCANNING PRIMARY INSURANCE COMPANY MEMBER ID GROUP NO._ POLICY HOLDER INFORMATION: NAME DATE OF BIRTH SOC. SEC. # SEX: ( ) M ( ) F PATIENT S RELATION TO INSURED_ SECONDARY INSURANCE COMPANY_ MEMBER ID_ GROUP NO. POLICY HOLDER INFORMATION: NAME DATE OF BIRTH SOC. SEC. # SEX: ( ) M ( ) F PATIENT S RELATION TO INSURED INSURANCE AUTHORIZATION AND ASSIGNMENT IF YOU HAVE NO INSURANCE, YOU WILL BE REQUIRED TO PAY AT TIME OF SERVICE. IF YOUR INSURANCE REQUIRES A REFERRAL AND YOU DO NOT HAVE ONE, YOUR APPOINTMENT WILL HAVE TO BE RESCHEDULED. I HEREBY AUTHORIZE PAAYAL P. MEHTA, M.D. TO FURNISH INFORMATION TO INSURANCE CARRIERS CONCERNING MY ILLNESS AND TREATMENTS AND I HEREBY ASSIGN TO DR. PAAYAL P. MEHTA, ALL PAYMENTS FOR MEDICAL SERVICES RENDERED TO ME OR MY DEPENDENTS. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE. DATE SIGNATURE

2 General Surgery Bariatric Surgery Laparoscopic Surgery Breast Surgery Paayal P. Mehta, M.D., F.A.C.S MEDICAL HISTORY NAME: DATE: AGE: HEIGHT: WEIGHT: OCCUPATION: MARITAL STATUS: MARRIED DIVORCED SINGLE PARTNERSHIP PLEASE TELL US WHO REFERRED YOU TO OUR OFFICE: WHAT BRINGS YOU TO OUR OFFICE TODAY? ARE YOU HAVING ANY OF THE FOLLOWING SYMPTOMS? HEADACHES STRESS INCONTINENCE SHORTNESS OF BREATH INDIGESTION/HEARTBURN COUGH VOMITING PALPITATIONS ABDOMINAL PAIN CHEST PAIN BLOOD IN URINE/STOOL DIZZINESS DIFFICULTY URINATING FATIGUE PAIN/SWELLING IN LEGS CONSTIPATION VARICOSE VEINS JOINT/MUSCLE PAINS DEPRESSION ANXIETY INSOMNIA SNORING EXCESSIVE DAYTIME SLEEPINESS IMPOTENCE FALL ASLEEP INAPPROPRIATELY HAVE YOU HAD OR DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING ILLNESSES/DISEASES? HEART DISEASE DIABETES HIGH BLOOD PRESSURE HEART ATTACK STROKE HIGH CHOLESTEROL ASTHMA EMPHYSEMA/COPD DEPRESSION CONGESTIVE HEART FAILURE ARTHRITIS CANCER KIDNEY DISEASE GLAUCOMA/ EYE PROBLEMS SLEEP APNEA GALLBLADDER DISEASE GASTRO ESOPHAGEAL REFLUX DISEASE (GERD) POLY CYSTIC OVARIAN SYNDROME (PCOS) LUPUS/OTHER COLLAGEN DISEASE ULCER/GASTROINTESTINAL DISEASE THYROID DISEASE HYPER OR HYPO (PLEASE CIRCLE ONE)

3 SOCIAL HISTORY: DO YOU CURRENTLY SMOKE CIGARETTES? #OF CIGARETTES/DAY IF NO, HAVE YOU EVER SMOKED CIGARETTES IN THE PAST? YES NO # OF CIGARETTES/DAY DATE QUIT DO YOU DRINK ALCOHOL? NO SOCIAL OCCASIONAL DAILY DO YOU HAVE ANY HISTORY OF DRUG OR ALCOHOL ABUSE? IF YES, PLEASE LIST: ARE YOU PRESENTLY TAKING ANY MEDICATIONS? NO YES IF YES, PLEASE LIST OR PROVIDE LIST: MEDICATION DAILY DOSE FREQUENCY ARE YOU ALLERGIC TO ANY MEDICATIONS/FOOD? NO YES IF YES, PLEASE LIST: HAVE YOU EVER BEEN HOSPITALIZED FOR ANY ILLNESS OR SURGERY? IF YES, PLEASE LIST BEGINNING WITH THE MOST RECENT: FOR OUR FEMALE PATIENTS: NUMBER OF PREGNANCIES NUMBER OF CHILDREN ARE YOUR MENSTRUAL PERIODS REGULAR? YES NO AGE OF MENOPAUSE DATE OF LAST PAP DATE OF LAST MAMMOGRAPHY

4 FAMILY HISTORY: IF LIVING IF DECEASED AGE HEALTH AGE OF CAUSE OF DEATH DEATH FATHER MOTHER BROTHER(S) SISTER(S) DO ANY BLOOD RELATIVES HAVE / HAD: CANCER TUBERCULOSIS DIABETES HEART DISEASE HIGH BLOOD PRESSURE STROKE BREAST MASSES OR BREAST TUMORS NO YES IF YES, WHO?

5 715 ROANOKE AVENUE, SUITE 1, RIVERHEAD, NY SILLS ROAD, SUITE 205, EAST PATCHOGUE, NY Ph: Fax: Paayal P. Mehta, M.D., F.A.C.S. We are required by law to maintain the privacy of our patients and provide individuals with our Notice of Privacy Practices with respect to your protected health information. If you have any objection to this form, please ask to speak with our HIPAA Compliance Officer in person or by telephone at (631) Patient Authorization for Use and Disclosure of Protected Health Information By signing, I authorize Long Island Bariatric, PLLC to use and/or disclose certain protected health information (PHI) about me to. (name of friend, relative, spouse, etc.) Signature below is only acknowledgement that you have received this notice of our privacy practices. Print Name: Signature: Date:

6 715 Roanoke Ave, Suite 1, Riverhead, NY Sills Road, Suite 205, East Patchogue, NY Phone: (631) Fax: (631) Paayal P. Mehta, M.D., F.A.C.S General Surgery Bariatric Surgery Laparoscopic Surgery Breast Surgery GUARANTOR AGREEMENT I. Individual s Responsibility for Non-Covered Services In consideration of services rendered by Dr. Paayal Mehta to the undersigned patient, the undersigned promise(s) to pay Dr. Paayal Mehta any co-payment, coinsurance or other charges required to be paid by my health insurance coverage. In addition, I promise to pay for all services that are not covered by my health insurance plan provided I am informed of same prior to the rendering of said services. If a surgical assist is required and the assistant does not participate with my insurance, I will be responsible for fees incurred for the services rendered. II. Assignment of Benefit Proceeds I hereby assign to Dr. Paayal Mehta all monies and or/benefits to which I am entitled from my insurer/hmo/third-party payor, government agencies, or those who are financially liable for my medical care. III. Authorization to Release Records I hereby authorize Dr. Paayal Mehta to release to my insurer/hmo/third-party payor, governmental agencies, or to whomever is financially responsible for my medical care, all information needed to substantiate payment for such medical care and, if required, for precertification/prior approval purposes. It is, however, expressly understood that there will be no obligation of the undersigned to pay for any services that are improperly billed. SIGNATURE OF PATIENT OR AUTHORIZED REPRESENTATIVE DATE SIGNATURE OF AUTHORIZED REPRESENTATIVE OF DR. PAAYAL MEHTA DATE

7 715 ROANOKE AVENUE, SUITE 1, RIVERHEAD, NY SILLS ROAD, SUITE 205, EAST PATCHOGUE, NY Paayal P. Mehta, M.D., F.A.C.S. Attention: Patients of Long Island Bariatric, PLLC RE: Fee for missed appointments and appointments not cancelled 24 hours in advance If you are a patient of Long Island Bariatric, PLLC and you cannot keep your appointment, you must notify the office 24 hours prior to the day you are scheduled. Patients that fail to show up for their appointments that are scheduled with Deborah L. Sforza, R.D., CDN, Christina Harrington, R.D., or Iris Pappalardo, R.N., LCSW-R without notifying the office 24 hours in advance will be charged a fee of $ Patients that fail to show up for an appointment scheduled with Dr. Paayal Mehta without notifying the office 24 hours in advance will be charged a fee of $ Patients that cancel their appointment at least 24 hours before the day of their appointment will not be charged any fee. Missed appointments without calling the office wastes time, is inefficient, and denies our other patients the ability to schedule their appointments on those days. In order for our office to provide the best care and services possible, we need the help and cooperation of our patients. Let us all work together. Thank you for you cooperation. Signature: Date:

Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION

Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION PATIENT INFORMATION Name: Date of Birth: Sex: Male Status: Single Married Divorced Widowed Other 502 Elm Street NE Language: Female Race: American Indian or Alaska Native Native Hawaiian or Or Pacific